Speaking up or remaining silent about patient safety concerns in rehabilitation: A cross‐sectional survey to assess staff experiences and perceptions

Abstract Background and Aims Patient safety incidents may be prevented if healthcare workers speak up to voice their concerns when they observe hazardous clinical situations. This study aims to investigate the frequency of speaking up and healthcare workers' perception of organizational climate in rehabilitation clinics. Methods An online survey was conducted in five rehabilitation clinics. An existing survey instrument (Speaking Up About Patient Safety Questionnaire [SUPS‐Q]) was adapted for this purpose. The instrument includes items on self‐reported speak‐up‐related behavior (perceived safety concerns, withholding voice, and speaking up), anticipated speak‐up behavior, barriers to speaking up, and speak‐up‐related climate measures (psychological safety, encouraging environment, and resignation). Data analysis included descriptive statistics, one‐way analysis of variance for differences between groups, multiple regression, and measures for validity and reliability of the scales. Results Four hundred seventy‐one individuals participated in the survey (response rate of 32%). In the 4 weeks preceding the survey, 81% of respondents had specific concerns about patient safety, 83% performed speak up and 41% remained silent in one or more instances. Expected differences between professional groups were confirmed, but surprisingly, we found no effect of hierarchical level on speaking up behavior and perception of the speak‐up climate. Factors that most frequently prevented healthcare workers from speaking up were ineffectiveness (38%), presence of patients (26%), and unpredictability of the actor's reaction (25%). The psychometric evaluation of the adapted SUPS‐Q showed acceptable results for validity and reliability. Conclusions Healthcare workers in rehabilitation clinics frequently perceive safety concerns. The study underlines the importance of promoting a culture of safety and speaking up. The short survey instrument SUPS‐Q can be used by rehabilitation clinics to initiate discussions related to facilitators and barriers to speaking up and to identify areas for improvement within the organization.


| INTRODUCTION
In clinical care, healthcare workers (HCWs) often encounter situations, which raise concerns about patient safety or require clarification. 1,2 In these situations, open communication is crucial to prevent errors from reaching the patient and causing harm. [3][4][5] The act of assertively voicing concerns, asking a question, or stating an opinion when one becomes aware of a hazardous clinical situation has been defined as "speaking up." 1,6,7 In addition to avoiding adverse events, speaking up in critical situations can prevent colleagues from making mistakes with potentially serious emotional consequences. 8 Addressing safety concerns can also launch individual and organizational learning processes that help ensure that future patients and HCWs are not exposed to the same risks. 9 Despite a strong motivation to protect patients from harm, many HCWs have encountered situations in which they found it challenging to speak up or where they even decided to withhold their concerns despite the potential risks. 2,10,11 Different factors influence the decision to speak up or remain silent. Personality traits, educational background, and previous experiences of speaking up and its consequences factor in, as do organizational factors such as hierarchical structures and visible organizational and leadership support. The decision to speak up is also influenced by contextual factors such as clarity or ambiguity of the clinical situation and the perceived severity of harm to the patient. 6 While raising safety concerns is usually associated with positive outcomes (i.e., preventing physical harm to patients), speaking up can also come with costs to the individual (e.g., negative response from others) and is thus antecedent by a personal trade-off between presumed benefits and potential risks. 7,11 Effective team communication is crucial for the safe provision of rehabilitation care. A review of interprofessional team communication in rehabilitation found that teams with strong communication demonstrated shared values and mutual trust and respect, which includes the ability to openly express opinions during clinical discussions. 12 It is, therefore, reasonable to assume that patient safety in rehabilitation clinics can be enhanced by encouraging and promoting speaking up in care teams. To our knowledge, however, speaking up has not yet been the subject of research in this healthcare setting.
The "Speaking Up About Patient Safety Questionnaire" (SUPS-Q) is a short survey instrument developed for acute care hospitals. It allows organizations to assess staff behaviors, experiences, and perceptions related to speaking up. 13 With this study, we aimed to adapt and pilot the SUPS-Q in rehabilitation clinics, to gain insights as to how often HCWs perceive safety concerns, how often they chose to speak up or remain silent, and how they perceive organizational climate relevant for speaking up in their organization.

| METHODS
The SUPS-Q has been validated for use in acute care hospitals. 13 To make it accessible to other healthcare settings, we conducted two studies with identical designs to adapt the instrument for inpatient rehabilitation and psychiatric hospitals. In this present paper, we report results for the adaptation of inpatient rehabilitation clinics. Results for the adaptation of psychiatric hospitals have recently been reported. 14

| Survey instrument
In the first section of the SUPQ-Q, three scales with a total of 11 items assess respondents' self-reported perceived safety concerns and frequency of withholding voice and speaking up. All items are rated on a 5point scale from "never" (0 times in the past 4 weeks) to "very often" (>10 times in the past 4 weeks). Higher frequencies of past behaviors result in higher mean scale values. The second section includes one multiplechoice item covering six predefined barriers to speaking up. The third section surveys respondents' perception of speak-up-related climate at their workplace. The 11 items are organized into three subscales addressing psychological safety (five items), encouraging environment (three items), and resignation (three items). All items are rated on a 7-point Likert scale, where the margins were labeled "strongly disagree" and "strongly agree." Higher mean scale values indicate higher levels of perceived psychological safety, higher levels of perceiving an encouraging work environment, and higher levels of resignation towards speaking up.
Lastly, the questionnaire includes a vignette to assess the respondents' anticipated behavior. After reading a hypothetical situation, respondents are asked to rate the realism of the situation, the expected risk for patient harm, their own likelihood to speak up, and their discomfort with speaking up in such a situation on a 7-point response scale.
Fourteen health professionals with various backgrounds were invited to join a working group to discuss the necessary changes to make the SUPS-Q applicable to rehabilitation clinics. The group suggested some changes to the wording of questions and response items to make them more comprehensible for rehabilitation staff. However, no items from the original questionnaire were removed or altered in content and no new items were added. There were some controversies over the vignette.
While some group members judged the situation described in the standard SUPS-Q version (a missed hand hygiene before wound inspection during daily rounds) to be realistic, others suggested that a missed hand hygiene situation related to a patient placed in isolation would more adequately depict safety concerns in their area of work. As no consensus could be reached, it was decided to test both options (see Table 4 for wording). Participants randomly received a questionnaire with either vignette 1 or 2.

| Study population and procedures
The online survey was administered in five rehabilitation clinics in Switzerland (convenience sample) in October-November 2018. Participating clinics ranged in size from 34 beds to 250 beds. All clinics provided inpatient services after hospital discharge. All HCWs with direct patient contact were invited to participate in the survey. Local study coordinators at each site were responsible for identifying eligible staff members and sending an e-mail invitation with the link to the anonymous online questionnaire. HCWs could choose not to participate and survey completion was considered informed consent. Participants were informed that the results of the survey would be used for research purposes to validate the adapted version of the SUPS-Q and that they would be notified about the results for their respective clinics. The online survey could be accessed for 4 weeks, one or two reminders were sent at each site. (good fit ≤0.08). [15][16][17] One-way analysis of variance was used to determine differences in mean scores between professional groups (nurses, physicians, therapists) and levels of hierarchy (high/low).

| Data analysis
Respondents' managerial function (yes/no) was used to determine the level of hierarchy. We expected climate scores to be higher for physicians and staff with managerial function, as compared to nurses and staff without managerial function, respectively. 13 In addition, we hypothesized that staff members frequently caring for patients requiring acute medical care (e.g. wound care, high-risk medication) had higher levels of safety concerns and withholding voice than their colleagues. Necessity to speak up is often perceived in situations where norms or standards are violated. 1 It seems likely that with the increased provision of acute medical care in rehabilitation clinics, the number of rules and standards related to high-risk care increase, and concerns for safety gain relevance. Lastly, we used multiple regression to analyze the relationship between anticipated likelihood to speak up and perceived risk of harm, hierarchical level, and professional group. [18][19][20] For all analyses, p < 0.05 was considered statistically significant. All analyses were performed with Stata 14.1.

| Psychometric evaluation of survey instrument
For the behavior-related items, Cronbach's α indicated good internal consistency for all three scales ( Table 2)

| Speak-up behavior
In the 4 weeks preceding the survey, 81% of respondents had perceived specific concerns about patient safety in one or more instances. During the same time span, most participants (83%) had voiced their concerns at least once. Yet, many also stated that there had been at least one or more instances where they had decided not to bring up concerns (41%), keep important information (23%), or not address rule violations (40%) (

| Speak-up climate
Total climate scores were significantly lower for nurses and therapists compared to physicians (

| Barriers to speaking up
The most frequently reported barrier to speaking up was ineffectiveness (38%), followed by the presence of patients (26%) and the unpredictable reaction of the person causing concerns (25%).
The assessment of the barriers differed in part between professional groups ( Figure 1). Ineffectiveness was reported more frequently as an important barrier by both nurses and therapists as compared to physicians (p = 0.006), as was the unpredictable reaction of the person causing concerns (p = 0.01). For therapists, the unclear risk in a situation represented more often a barrier than for nurses and physicians (p = 0.01).

(<1)
… did you not address a colleague a if he/she didn't follow, intentionally or unintentionally, important patient safety rules?
174 (42) 143 (34) 72 (17) 24 (6) 4 (1) a Colleagues is defined as "across professional groups and hierarchies."  Expected differences between professional groups were confirmed. Nurses speak up more frequently, but they also decide to remain silent more often than physicians. Qualitative studies suggest that nurses may be hesitant to speak up due to perceived lack of support, instances of being ignored, and experiences of being disrespected. 21 The feeling of resignation can foster withholding voice. This is reflected in our results where ineffectiveness was the main barrier reported by nurses and therapists. Compared to acute care, rehabilitation care is characterized by greater involvement of therapeutical staff such as physical or occupational therapists. In our survey, we found that response patterns from therapists were comparable to those of nurses, that is, they speak up, but also withhold their voice frequently. Therapists oftentimes face clinical situations that require an intervention to prevent potential harm but may be insecure about the risk of harm or wary that their concerns may not be heard. By training and supporting them to effectively communicate within the care team, their role as important agents for patient safety can be acknowledged and fostered.
Surprisingly, we found no effect of hierarchical level on speaking up behavior and perception of speak-up climate in our sample.
Previous studies in the hospital setting have concluded that status F I G U R E 1 Relative frequencies of self-reported barriers to speaking up, by professional group.  You are on a daily round as part of an interdisciplinary team (doctors, nurses, therapists) with a patient who had been placed in isolation due to a Norovirus infection. The senior physician greets the patient with a handshake. He does not wear gloves. When entering the next patient's room, you notice that the senior physician did not disinfect his hands again.   One way analysis of variance for differences in mean ratings between respondents of different professional groups and hierarchical levels.
NIEDERHAUSER AND SCHWAPPACH | 7 of 10 asymmetry greatly affects speaking up behavior and perception of safety climate, 21,22 but these dynamics were not predominant in our sample. This may result from bias due to self-selection of participants less susceptible to power dynamics. Greater proximity of leaders to clinical work, moderate-sized teams, and stronger social skills among leaders in rehabilitation care may also help to explain our findings.
More research is needed to understand how authority gradients affect speak-up behavior in rehabilitation care as compared to acute care hospitals.
Finally, we found that HCWs frequently caring for patients requiring acute medical care had higher frequencies of safety concerns, speaking up and withholding voice, and less positive climate scores than their colleagues. This supports our hypothesis that speaking up is of high-and probably growing-relevance for HCWs in rehabilitation clinics. A study in Australia found that between 2007 and 2016, patients admitted to inpatient rehabilitation became more complex and dependent. 23 The increased provision of acute medical care has implications for the delivery of rehabilitation services and the skills required of HCWs to provide these services. There

| LIMITATIONS
The study has some limitations. The response rates ranged from low (26%) to good (47%) between the clinics. We cannot exclude selection bias in this study. Staff members' willingness to participate in the survey may have been affected by past positive or negative experiences of speaking up. As there was no data about nonrespondents available, we could not assess the representativeness of the study sample. We relied on self-reported measures to examine the extent of speak-up behavior among HCWs, making our results susceptible to response and recall bias. Single experiences of patient safety incidents may be overrepresented in individuals' memory, which could result in higher frequencies of reported behaviors.
However, due to its spontaneous nature, it is difficult to objectively measure speak-up behavior in practice. More importantly, withholding voice is a "nonbehaviour" not easily accessible to observation.
New methodologies, such as analyzing verbatim transcripts of speakup interactions or designing simulation experiments have been proposed to overcome some of the methodological limitations of self-reported data. 7,27 Finally, the results of the regression analysis may be subject to common methods bias (CMB) as both predictor and outcome variables were obtained within the same survey. 28 We asked for only a few personal data and ensured participants their anonymity at various instances (invitation, start of the survey, etc.) to minimize social desirability bias as one source of CMB. Other recommended procedural remedies, for example, separating predictor and outcome variable measurements by a time lag, seem not appropriate in a vignette study design in which outcome and predictor ratings need to be organized closely around the vignette. The relevance of CMB has been questioned recently and ex post statistical control of CMB, such as marker variable approaches, have not been recommended for general application. 29,30 6 | CONCLUSIONS Using a previously validated short survey instrument adapted to the rehabilitation setting, we were able to demonstrate the importance of promoting a culture of safety and speaking up. We found that safety

CONFLICTS OF INTEREST
The authors declare no conflicts of interest.

TRANSPARENCY STATEMENT
The lead author (manuscript guarantor) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

DATA AVAILABILITY STATEMENT
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

ETHICS STATEMENT
The study does not require full ethical review according to the Human Research Act, as confirmed by the Ethics Committee of the Canton of Zurich, Switzerland (BASEC-Nr. Req-2018-00681).